A Cross-National Comparison of Institutionalized Tube-Fed Older Persons: The Influence of Contrasting Healthcare Systems

Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy

A previous study conducted more than 15 years ago in Israel found a high overall use of tube-feeding for institutionalized end-stage dementia patients (52%) and a proportionally higher use (2:1) of naso-gastric tube (NG) over Percutaneous Endoscopic Gastrostomy (PEG) tubes for enteral feeding. This rate was markedly higher than that observed in other western countries (4.9-34%), and did not conform with clinical guidelines preferring spoon-feeding over tube-feeding for these patients, and PEG over NG for those in whom tube-feeding was initiated in long-term care. Over the past decade, the Israeli Ministry of Health conducted a policy reform to neutralize the administrative incentives presumed to be responsible for this situation. Further administrative and legislative developments followed suit. Despite these, we found no significant reduction in the prevalence of tube-feeding over spoon-feeding. However, we did observe a reduction in the proportional use of NG over PEG.

Insights Into Oropharyngeal Dysphagia From Administrative Data and Clinical Registries: A Literature Review

Purpose

The call for data-driven health care has been bolstered by the digitization of medical records, quality initiatives, and payment reform. Administrative databases and clinical registries are increasingly being used to study oropharyngeal dysphagia and to facilitate data-driven decision making. The objective of this work was to summarize key findings, etiologies studied, data sources used, study objectives, and quality of evidence of all original research articles that have investigated oropharyngeal dysphagia or aspiration pneumonia using administrative or clinical registry data to date.

Method

A literature search was completed in MEDLINE, Scopus, and Google Scholar (January 1, 1990, to February 1, 2017). Each study that met inclusion criteria was rated for quality of evidence on a 5-point scale.

Results

Eighty-four research articles were included in the final analysis (n = 221-1,649,871). Over the past 20 years, the number of new publications in this area has quintupled. Most of the administrative database and clinical registry studies of dysphagia have been retrospective cohort studies and cross-sectional studies and limited to quality of evidence levels of 3-4. In these studies, much has been learned about risk factors for dysphagia and pneumonia in defined populations and health care costs and usage. Little has been gleaned from these studies regarding swallowing physiology or dysphagia management.

Conclusions

Investigators are just beginning to develop the methods to study oropharyngeal dysphagia using administrative data and clinical registries. Future research is needed in all areas, from the fundamental issue of how to identify individuals with dysphagia with high sensitivity in these data sets to evaluating treatment effectiveness.

Supplemental Material

https://doi.org/10.23641/asha.6066515.

Feasibility of a web-based dementia feeding skills training program for nursing home staff

Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.

Unintended weight loss in the elderly living at home: the aged in Home Care Project (AdHOC)

OBJECTIVE

To describe associations between unintended weight loss (UWL) and characteristics of nutritional status.

DESIGN

A comparative cross-sectional assessment study at 11 sites in Europe. The target population was a stratified random sample of 4,455 recipients of home care (405 in each random sample from 11 urban areas) aged 65 years and older.

MEASUREMENTS

the Resident Assessment Instrument for Home Care, version 2.0. Epidemiological and medical characteristics of clients and service utilisation were recorded in a standardized, comparative manner. UWL was defined as information of 5% or more weight loss in the last 30 days (or 10% or more in the last 180 days).

RESULTS

The final sample consisted of 4,010 persons; 74% were female. The mean ages were 80.9 +/- 7.5 years (males) and 82.8 +/- 7.3 years (females). No associations were found between single diagnoses and UWL, except for cancer. Cancer patients were excluded from further analyses. Persons with a Cognitive Performance Scale value (CPS) superior 3 (impaired) had increased risk of UWL (OR = 2.0) compared with those scoring inferior or egal 3 (less impaired). Only in the oldest group did we find a significant association between UWL and reduction in ADL and IADL functions, comparing those who scored 3 or less with those who scored more than 3 (disabled). A binary logistic regression model explained 26% of UWL: less than one meal/day, reduced appetite, malnutrition, reduced social activity, experiencing a flare-up of a recurrent or chronic problem, and hospitalisation were important indicators.

CONCLUSION

We recommend a regular comprehensive assessment in home care to identify clients with potential risk factors for weight loss and malnutrition, in particular those discharged from hospital, and those with physical dependency or cognitive problems. This study may provide incentives to create tailored preventive strategies.

The 'natural' endpoint of dementia: death from cachexia or dehydration following palliative care?

OBJECTIVES

To investigate the causes of death in nursing home patients with dementia, and to compare causes of death in patients who survive until the final phase of dementia with those who die before reaching that phase, adjusted for potential confounders.

DESIGN

Observational analysis of a cohort of patients with a prospective follow-up.

SETTING

Psychogeriatric nursing home 'Joachim en Anna' in Nijmegen, the Netherlands.

PARTICIPANTS

Eight hundred and ninety dementia patients admitted between 1980 and 1989. All patients were followed until death.

MEASUREMENTS

The final phase of dementia was defined as total impairment on 20 items of a functional status questionnaire. Immediate causes of death (part 1a of the Dutch death certificate) were classified by the International Classification of Health Problems in Primary Care.

RESULTS

The three most important reported immediate causes of death were cachexia/dehydration (35.2%), cardio-vascular disorders (20.9%) and acute pulmonary diseases (20.1%), mainly pneumonia. Cachexia/dehydration was particularly common as a cause of death of patients who survived to the final phase (53.2%); survival to the final phase of dementia was an independent predictor of cachexia/dehydration as an immediate cause of death with reference to cardiovascular disorders in multinomial regression adjusted for age at death, gender, and type of dementia.

CONCLUSION

Patients who survive to the final phase of dementia are more likely to die from cachexia or dehydration than those who die before. The findings contribute to a debate on what should be reported as the immediate cause of death in dementia including perspectives from a palliative care viewpoint.

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison

OBJECTIVE

To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes.

DESIGN

Retrospective cohort study.

SETTING

A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option.

MEASUREMENTS

Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion.

RESULTS

Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding.

CONCLUSIONS

Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.